2013_0411 (25)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # Q
LOCATION OF SERVICE: _ s'
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
b
Serial Number v_,. -� q 7 LQ
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size �
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge # %g 1
Date last accuracy tested % 1 1.2
Certified ?ester ' `
Cert. Testa No. V001 y'I 1 % Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # %g 1
Date last accuracy tested % 1 1.2
Certified ?ester ' `
Cert. Testa No. V001 y'I 1 % Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy